Adaptation of Residents to Consultation-Liaison Psychiatry 11. Working with the Nonpsychiatric Staff Samuel Perry, M.D. Associate
Milton Viederman, Professor of Clinical
Cornell University Medical College, Payne Whitney Clinic, New York,
Consultation-Liaison New York
Abstract: Wken working witk tke stuff in a genera1 kospital, psyckiatry residents may be overly competitive, solicitous, or detacked. These defensive reactions often arise because of tke special ckallenges of performing a consultation, including tke skepticism about tke value of psyckiaty and tke demeaning ar unrealistic expectations about wkat tke psyckiatrist can do. Furtkermore, tke psyckiaty resident feels even more ckallenged if tke attitudes and bekavior of tke staffmust be ckanged for tke patient’s benefit. To affect tkis inftuence on tke staff tke psyckiaty resident may need to assume a “liaison stance.” Tkis stance involves nat only establiskinga collegial alliance but also using modified tkerapeutic maneuvers to alter stuff bekavior. By applying psyckodynamic knowledge to understand and potentially to influence tke staff, psyckiaty residents, as participant obsewers, can fee1 less kelpless and frustrated by difficult liaison situations.
The consulting psychiatrist can engage and influence the physically ill patient by assuming a “therapeutic stance,” requiring deviations from neutrality, abstinente, and anonymity and awareness of the particular style and psychodynamics of the patient. Similarly, certain situations on a genera1 hospita1 ward may require that the psychiatrist engage and influence the staff by utilizing a “liaison understance,” which applies a psychodynamic standing of human behavior.
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The Challenge of a Liaison Consultation Psychiatry residents are not unique in feeling challenged when asked to do a consultation on a hospitalized patient. Any consultant is an outsider who is temporarily admitted to the ward culture at the request of a high status member (1). To gain respect, this invited specialist must meet the expectations defined by the group. Competitive feelings between different specialists may be evoked without excessive friction or harm and may, in fact, motivate the consultants to work with special care in order to reveal their expertise and the value of their specialties (2). Although consultations may present a competitive challenge to al1 specialists, psychiatry residents have several reasons to be more sensitive in performing consultations in a genera1 hospital. First, skepticism about the value of psychiatry is more pervasive than with other specialties (3-6) and the residents, therefore, may fee1 they have more to prove. Second, the psychiatic consultant is usually more of an outsider than other specialists, with the bulk of his work done in a section of the hospita1 geographically and socially distant from the medical-surgical wards. The psychiatry resident feels like an ambassador in a foreign territory, far removed from his office, regular patients, and supportive colleagues. Third, psychiatry residents are less familiar and, therefore, less comfortable with
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the kind of regular exposure and scrutiny experienced by other specialists on rounds, in the operating room, at the nurses’ station, or in charts. Psychiatrie work tends to occur and be evaluated more privately behind closed doors, and the more public requirements of a consultation can be distressing. Finally, psychiatry residents may find consultations especially challenging because the expectations of the referring physician can be either demeaning or unrealistic. On the one hand, the requesting doctor may have very limited expectations of what psychiatry can offer; there is the implication that the psychiatrie consultant can take the time to comfort and console the physically ill patient while the “real” doctors treat the more serious problems. On the other hand, the referring physician may expect the psychiatic consultant to resolve the most difficult and complex psychological, ethical, social, or legal problems; for example, a psychiatrist may be asked to transfer a suicidal patient from the intensive care unit to a psychiatry ward (where medical care would be inadequate), or to prevent a patient from discontinuing hemodialysis (which is a complicated ethica1 problem), or to arrange a suitable disposition for an impoverished and demented elderly man (which is a social dilemma), or to declare incompetent a seriously ill patient who is leaving the hospita1 against advice (a declaration only the courts can make), and so on. More than any other specialty, psychiatry invites such a wide range of expectations because the boundaries of the field are not wel1 demarcated. Unless the expectations of the referring physician can in some way be clarified or modified during the process of consultation, the psychiatry resident must contend with the paradox of being asked by a nonpsychiatric colleague to do too little or too much. Because of these special challenges of a psychiatrit consultation-the skepticism about the specialty, the geographical and social distance from the medical services, the public exposure and criticism, the discrepant expectations of the referring physicianspsychiatry residents understandably tend to be more confident when the consultation approximates a familiar and defined psychiatrie problem that can be treated competently with minimal interaction with the nonpsychiatric staff. In contrast to these patient-oriented consultations, the consultee-oriented consultations with more staff involvement tend to be less comfortable for psychiatry residents (7,8). As the liaison component of the consultation 150
becomes more prominent, the psychiatry resident is often confronted with problems that are more ambiguous, that lead to a collision between the biomedical and biopsychosocial approaches to clinical problems (9), and that require ways of influencing others without the benefit of an established therapeutic alliance. The following vignette illustrates this spectrum between consultation and liaison functions and how the psychiatry resident experiences more challenge and potential frustration as involvement with the nonpsychiatric staff increases: A psychiatry resident was asked to see a 50-year-old woman who became severely depressed in the hospital after a infarction. myocardial From a psychodynamic and biological point of view, this episode of her bipolar affective illness was most fascinating, and with supportive psychotherapy and antidepressants the patient responded welk From a liaison point of view, however, little was involved: the referring internist accepted the psychiatrist’s suggestion about medication and an approach to the patient, and the consultation concluded with the psychiatry resident’s feeling respected and helpful. About a month later, this same psychiatry resident was asked by the same internist to see a 25-year-old “addict” after she was caught hiding an assortment of drugs in her bedside table. The patient was being treated for acute endocarditis, probably caused by intravenous drug abuse, so the staff understandably was upset about this discovery. Furthermore, her seductive and provocative behavior had already made the male physicians uneasy and the nursing staff angry. After talking at length with the patient and the head nurse, the psychiatry resident concluded that the patient had a severe borderline personal+ disorder, that she used drugs to treat her diffuse anxiety and profound emptiness, and that simply reprimanding or warning her about taking drugs would not be sufficient. A consistent, firm, yet supportive approach by al1 the staff would be necessary if she were going to stay for adequate medical treatment and eventually consider a drug rehabilitation program. When the psychiatry resident tried to discuss a suggested plan for managing this difficult patient, the referring physician showed no interest. He insisted that the patient be admitted to a psychiatrie unit and did not accept the psychiatrist’s explanation about why the patient would never agree to such a transfer. The following day the psychiatrist returned to see the patient and learned that she had “picked a fight with the doctors” and left the hospita1 against advice. The consultation ended on this unpleasant note, in contrast to the mutual respect expressed during the previous consultation with the same internist when the liaison component was less involved.
Resident Adaptation to C-L Psychiatry. 11.
Each psychiatry resident wil1 of course respond to challenges in his own way and with variations depending on the case, but some maladaptive patterns must be avoided in order to develop the liaison stance. Three common maladaptive responses observed in the supervision of psychiatry residents are: (1) competitive; (2) solicitous; and (3) detached.
take on tasks that could be more appropriately performed by others; for example, they cal1 nursing homes to arrange dispositions, or cal1 other hospitals to obtain medical records, or make special trips to change an order for a psychotropic drug-chores that could appropriately be delegated to a social worker, a ward clerk, or intern, respectively. Eventually, such an overly solicitous approach leads to resentment in the psychiatry residents, who may react by failing to respond appropriately to reasonable requests by the staff.
feelings between specialists While competitive need not be destructive, some overly competitive psychiatrie residents approach consultations not only as a chance to use their expertise, but also as a chance to diminish nonpsychiatric colleagues who are perceived as threatening. When most overt, this competitive attitude is displayed in the chart, where the psychiatrie note tactlessly points out deficiencies in the medical management rather than focusing on the reason for consultation. When more covert, destructive competition may subtly encourage the nursing staff to express resentful feelings toward the nonpsychiatric physicians and to view the psychiatrist as the more understanding and compassionate figure. Psychiatry residents may also try to enhance their own worth by eliciting in patients negative feelings toward the “unempathic” primary physicians.
The challenge of working in a genera1 hospita1 causes some residents to handle anxiety by a type of avoidance behavior. Although they fulfill the clinical responsibility of performing requested consultations, their work remains patient-oriented and they make little attempt to become part of the ward culture. They may rationalize that they remain on the periphery to protect the confidentiality and necessary intimacy of the therapist-patient relationship, but, in fact, they are intimidated by some aspects of working with the nonpsychiatric staff. Furthermore, because they may not be aware of being threatened, they may not have examined what in particular is threatening and what aspect of the threat is neurotically determined. At the beginning of the consultation-liaison assignment, detached behavior may be subtle. Lack of involvement may be revealed by nothing more than unusual politeness in the nurses’ station, as if in a forma1 hotel lobby rather than as part of the treatment team of a busy medical service. Distance increases when no attempts are made to interact with the staff on a professional or personal level. Missing are efforts to ask questions about laboratory tests, surgical procedures, or antibiotics or to inquire socially of the intern’s or nurse’s workload. Uncorrected, this lack of involvement tends to escalate. Staff may begin to project doubts and fears about psychiatry onto the little-known residents. These projections may be partially accurate if, in fact, the psychiatry residents respond to increased alienation by defensively developing a scrutinizing attitude and by attempting to gain some control over the situation by finding character flaws in the staff and labelling suspected psychopathology. When the detachment becomes most destructive, it has passed from indifferente to contempt, an indignation the staff senses and rightfully resents. By this time, the prospects of collegialitv have been
Maladaptive Responses to Consultation-Liaison Psychiatry
solicifuus In some respects, every consultant performs a service for a colleague, but the overly solicitous psychiatry resident sometimes views himself as an “assistant” in awe of other kinds of physicians. These residents easily lose the respect of their colleagues and allow themselves to be exploited. They wil1 agree to console a patient, answer medical questions, or meet with visitors simply because the primary physicians have “no time.” They wil1 fail to convey the value of their own time, for example, by waiting around to interview a patient who has been taken to a routine x-ray, rather than making reasonable arrangements with the staff to have the patient available at a particular hour. S.eeing themselves a notch below the ward physicians and viewing psychiatry as a less substantial specialty, these solicitous psychiatry residents have difficulty delegating authority and thus
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lost. Residents may then not only overemphasize the differences between psychiatry and other medical fields, but also the differences between consultation-liaison work and other areas of psychiatry. They may resent the required rotation on the service and wait eagerly to resume being “real” psychiatrists.
The Liaison Stance The “liaison stance” is not a defensive reaction to the liaison situation, but is determined by thoughtfully applying knowledge of human behavior to engage and influence the nonpsychiatric staff. The “liaison stance” with staff parallels the previously described “therapeutic stance” used to engage reluctant patients by assuming certain spontaneous roles deviating from neutrality, anonymity, and abstinente. In the same way, the psychiatrie consultant may need to assume a “liaison stance” to overcome staff resistance by assuming an engaging role and to influence behavior on the ward by using various maneuvers, even if a firm working alliance with the staff has not yet been developed. Like the therapeutic stance, the liaison stance is determined by the style and dynamics of those involved and by the therapeutic goal which the maneuvers are designed to achieve. Instead of a neutral position, which by definition is “not engaged,” the psychiatrist uses his repertoire of social and professional responses to mesh with the staff. Some psychiatry residents have a natura1 capacity to resonate spontaneously with the various personalities of a treatment team by sharing, chatting, teasing, joking, and in other ways being sensitive to social clues and finding mutual professional and personal interests. Other less flexible psychiatry residents may argue that such “role playing” is phony. These more socially reserved residents should come to appreciate that the liaison stance does not require that the psychiatrist pretend to be a completely different person, but the stance does require using one’s maximum range of responses to provide a mode of engagement, just as one would relate differently to the neighborhood groter than to the university dean. The psychiatry resident performing liaison functions should therefore not expect to be completely unself-conscious on the medical ward, or at least not so totally relaxed as he may be among closest friends. As participant observers, liaison psychiatrists must, in fact, remain both en152
gaged and reflective, examining the behavior of themselves and others for the purpose of affecting the system most therapeutically. Psychiatry residents are often not clear about the differente between establishing a collegial relationship with the nonpsychiatric staff and learning how to influence others in specific situations. This confusion is reflected in the literature. Many authors have suggested ways to develop a liaison alliance without making explicit the differente between maneuvers designed Co become an accepted member of the group and maneuvers specifically designed to influence others. For example, Golden (10) suggests sharing the language and customs of the primary physician, including scrubbing with the surgical team; Moore (11) suggests being available for social as wel1 as clinical activities; Mohl(12) suggests seizing opportunities to apply interviewing and diagnostic ski&.; Strain and Grossman (13) suggest the use of didactic conferences; Lipowski (14) suggests regular attendance at rounds, projection of a medical image, and patience in enduring staff resistance; and in summarizing the liaison literature in this area, Schubert (15) includes collaborating in research and performing committee work as ways of forming a relationship with nonpsychiatric colleagues. Although these suggestions may help the psychiatrist to become an accepted, even respected member of the ward culture, they do not necessarily influence staff behavior. Psychiatry residents on assigned consultation-liaison services are often included more or less as part of the ward community and thereby acquire data from the inside about the dynamics of the system. The residents then find, however, that more than an alliance and information are necessary to effect change. By analogy, the therapeutic alliance of individual therapy brings the doctor and patient together and helps provide data (16), but this alliance is not in itself sufficient to produce therapeutic results; various interventions -such as clarification, interpretation, abreaction, suggestion, and manipulation (17)-must also be introduced. Furthermore, in some treatments these interventions can be used effectively in the absente of a firm alliance, as in certain brief therapies and crisis interventions (18,19). Similarly, a liaison alliance is not sufficient to modify the ward system. Although the alliance may bring the staff and the psychiatrist together, collegial contact is not enough. The liaison psychiatrist must learn to intervene effectively. In addition, some consultations are similar to brief therapies in
that the psychiatrist may need to influence the staff on a service where a liaison alliance has not been formed. A psychiatry resident must therefore appreciate that the liaison stance is not simply a way of being accepted as a member of the ward community (20); the stance is designed to engage the staff and affect behavior from inside, or if necessary from outside, the group. A psychiatry resident, during a consultation may recognize that some changes in the ward system are indicated, but may believe he has no means to effect such a change. This belief is based on a failure to recognize the potential of psychodynamic understanding and on a reluctance to use a modified form of psychotherapeutic intervention with “nonpatients,” particularly when consultees have an equivalent or even higher status in the system (such as chief residents or senior attendings). In fact, the liaison stance uses interventions that are not substantially different from those used in many psychotherapies. A case example illustrates this point: After four months on a consultation-liaison service, the resident mentioned above was confronted with the kind of clinical problem that had been so frustrating previously: a 28-year-old prostitute was being treated for complications of severe hepatitis caused by drug abuse and was suspected of having “weird” visitors bring her drugs. The involved and esoteric medical management was quite time consuming, which made her uncooperative attitude even that much more infuriating. In the intern’s words, the staff wanted her “locked up or back on the streets.” This time, by applying his knowledge of borderline mechanisms and ward dynamics, the psychiatrie consultant handled the situation quite differently in assuming an interventive liaison stance. First, during the interview with the patient, he not only elicited her rage at the many “bad objects” on the staff, but purposefully searched for and discovered a “good object,” a practica1 nurse who worked evenings and had grown up in the same ghetto neighborhood. Because this nurse was idealized as a loving, maternal figure, the patient agreed to have this caring nurse present during visiting hours, to search for drugs after the visitors left, and to administer sufficient amounts of “good medicine” at bedtime (methadone) so that the illicit, intravenous “bad medicine” would not be necessary and the liver could heal. This maneuver with the patient was followed by maneuvers with the staff, including the familiar techniques of abreaction, interpretation, generalization, clarification, suggestion, and manipulation. The psychiatrist entered the nursing station and expressed his frustration with the patient’s evasive and calculated
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replies. He thereby provided the surrounding
nursing staff a chance to vent their own frustration (abreact) and release the tension which was building up over this patient and which might potentially lead to an explosive confrontation and premature discharge. When the rather rigid head nurse warily let her own resentment toward the patient come out during this informal conference, the consultant dealt with her fear of being angry by mentioning (interprefing) that the impulse to wring a patient’s neck makes US fee1 guilty when we expect ourselves to be in control. After this exchange, the consultant summarized in the chart how this patient’s character problems were chronic and not specifically related to this hospitalization. Along with this generalizatiorz, to decompress the situation on the ward, the psychiatrist succinctly described in his note the ways in which borderline patients wil1 attempt to divide and aggravate the staff. This clarificution provided intellectual control and a sense of mastery. The note concluded with the recommended maneuver of using methadone and the “goed” nurse, who agreed to the plan. Finally, anticipating the referring physician’s wish to have the patient transferred or leave, the consultant designed a maneuver directed at this internist’s specific need to be seen as the wise and unruffled physician. In the presence of the interns and medical students on the service, the consultant began by saying that he suspected this patient understandably could make al1 the doctors so uncomfortable that they would try to force her into a psychiatrie hospitalization (which she would never accept and which could not provide the sophisticated medical treatment) or they would try to force her to leave the hospita1 before she finished treatment (which might be the death of her and prevent hopes of arranging for a rehabilitation program). The psychiatrist added that these kinds of patients require far more tolerante than most physicians have, including psychiatrists. A special kind of doctor would be needed to weather the inevitable storms of dissent this patient would produce throughout the ward. The referring physician felt properly challenged by these remarks and bound, perhaps unknowingly, by the use of suggestion and manipulafion. If he gave in to his wish simply to have the patient dismissed without further efforts, he would be exposing to others and to himself his limited tolerante for frustration. In addition, the psychiatrist avoided being scapegoated for the patient’s problems and being erroneously blamed for not transferring the patient to a psychiatrie unit. The struggle remained focussed on the patient, and the liaison alliance was strengthened rather than disrupted. In this case, the physician went out of his way to institute the psychiatrist’s recommendations and felt rightfully proud to show others and himself his capacity to tolerate the most exasperating personalities and to see a treatment through. Even if the maneuver 153
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had failed, the psychiatry resident would have had the satisfaction of applying his dynamic understanding of human behavior to a compelling clinical problem, rather than experiencing the consultation only as a source of personal frustration.
Ethica1 Considerations Regarding the Liaison Stance The maneuvers described in the above case inevitably raise certain ethica1 considerations, particularly the use of manipulation to influence the nonpsychiatric staff. Although manipulation is a standard psychotherapeutic technique (17), the connotation is pejorative. Gaylin, in a discussion of coercion (21), has noted that, like other kinds of power and influence, psychodynamic understanding has potential for abuse and demands ethica1 monitoring. Just as psychiatry residents are hesitant to use manipulation in therapy with patients, they are even more hesitant with “nonpatients” such as members of the medical staff. This reluctance may be overcome by showing how manipulation is used widely and therapeutically, for example, referring a particular patient to the right therapist, a form of manipulation used to match personalities and to provide-to manipulate-certain elements in the milieu for therapeutic purposes. Similarly, psychodynamic knowledge used to influence nonpsychiatric staff has the same therapeutic purpose as in individual treatment; interventions are not applied impulsively but only after careful reflection based on the available data. In this regard the maneuvers used in the liaison stance can be distinguished from the maladaptive response of “detachment,” described above. The liaison stance requires the consulting psychiatrist to discern the dynamics of the ward system in order to effect valuable change, whereas the detached residents use their knowledge of psychiatry not to engage but defensively to distance themselves from the staff. They label pathology from afar rather than act as participant observers to influence the ward’s milieu. The psychiatrie literature is relatively mute on how the consulting psychiatrist maneuvers a nonpsychiatric staff, perhaps because al1 parties are wary of making such potential manipulations explicit. The psychiatrists may not wish to acknowledge a mode of influence which has not been openly granted by other members of the ward community who expect the psychiatrist to help 154
manage patients and enhance the harmony of the service, but do not expect to be influenced covertly. The ethica1 concerns posed by the use of manipulation and suggestion cannot be minimized. The fundamental question is who decides that any particular goal justifies using psychodynamic understanding and influencing others without expressed knowledge. While the answer is beyond the scope of this paper, we suspect that we are not so much promulgating a new mode of action, as we are defining and making conscious maneuvers already used by psychiatrists in many kinds of therapeutic situations.
The Training Value of the Liaison Experience Unless the training goals of the liaison experience are clarified for the psychiatry residents, they may view working with the nonpsychiatric staff at best as a tolerable assignment unrelated to their future work with psychiatrie patients or at worst as a frustrating rotation where service requirements far outweigh training needs. The resident should be aware from the start that learning the liaison stance forces the psychiatrist to examine the dynamics of human behavior and that this examination in itself can enrich understanding. Furthermore, just as working with the physically ill provides an opportunity to encounter patients who under other circumstances might never see a psychiatrist, working with the nonpsychiatic staff also exposes the resident to unique situations. This exposure can only serve to broaden knowledge of human behavior, which must remain a primary goal of psychiatrie training. Along with increased understanding, a liaison experience can help the resident develop the skills of a participant observer (22). The liaison stance requires that the psychiatrist simultaneously interact and observe. Also, as in many psychotherapies, while participating and examining, the resident must search for modes of influence even when the therapeutic alliance is fragile or unformed. This search enlarges the resident’s repertoire of available responses. Finally, and perhaps most important, learning the liaison stance can help the resident appreciate the potential as wel1 as the limitations of psychodynamically informed therapeutic interventions. The resident’s belief in psychiatry as a specialty and in his capacities wil1 increase as difficult liaison situations are mastered by an applied
psychodynamic understanding. The resident’s acceptance of psychiatry’s limitations wil1 also develop as some situations fail to respond to attempted intervention. As in individual therapies, the resident wil1 not depend on effective results to enhance his self-esteem, nor can the resident depend on acceptance and praise of others. Certain patients and certain staff members wil1 never accept the psychiatrist’s perceptions or what he believes needs to be done. Some discordance is inevitable and satisfaction cannot depend on converting or totally meeting the expectations of others. Instead, the satisfaction wil1 be based more on an internally monitored system of rewards, which is a sign of professional confidence and maturity (23). The potential risks of an assignment to a consultation-liaison service should also be recognized. In many programs the rotations on the ward of a genera1 hospita1 represent the residents’ transition from the insulated psychiatrie community to the outside world and a first opportunity to expose one’s knowledge and therapeutic ski11 to colleagues. An experience that is seen as frustrating may persuade the future psychiatrist that the profession cannot stand up to scrutiny, cannot beneficially influence others, and may force him into a premature retreat from collaborating with medical colleagues (24). To avoid these potential risks, the consultation-liaison training program must provide the resident with adequate role models of effective liaison psychiatrists and provide time for seminars, supervision, and private reflection. The anxiety and the complexity involved in a liaison assignment cannot be mastered if the exposure is too compressed or frenetic.
Conclusion In discussing the adaptation of a psychiatry resident to a consultation-liaison assignment, we have described some temporary maladaptive responses and introduced the concept of the “liaison stance,” in which the psychiatrist applies a psychodynamic knowledge of human behavior and modified therapeutic techniques to engage and influence the nonpsychiatric staff. We believe the thoughtful quest for such an effective liaison stance can transform a frustrating liaison situation into an interesting clinical challenge. We further believe that the questions evoked by consultation-liaison work can serve to stimulate further inquiries and thereby enhance our understanding of human behavior.
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22. Sullivan HS: The Psychiatrie Norton, 1954
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23. Kohut H: Forms and transformations of narcissism. Am Psychoanal Assoc 14~243-272, 1966
24. Eaton JS et al: The educational challenge of consultation-liaison psychiatry. Am J Psychiatry 134 (March Suppl) 20-23, 1977
Samuel Perry, M.D. Consultation-Liaison Division Department of Psychiatry The New York Hospita1 Payne Whitney Clinic New York, NY 10021